Pulmonology Coding Alert

Question: I reported critical care (99291-+99292) for two encounters the pulmonologist had recently in the ICU, but the carrier denied one and requested additional documentation for the other. I really thought these situations merited critical care but now I hesitate to use the codes. Can you shed some light on when they are appropriate and what their link is to ICU encounters?

Wyoming Subscriber

Answer: Critical care can occur wherever the physician performs critical care on a patient -- the patient does not need to be in the intensive care unit (ICU) or emergency department.

What drives critical care is the patient's condition, not the location. However, if the pulmonologist provided care in an unusual location, such as the office or a clinic, it is a good idea to document why there was an unusual place of service for such a high-acuity treatment. Conversely, treating a patient in a location where critical care is common, such as the ICU, is not a guarantee that critical care occurred. Be sure to check the encounter notes before deciding whether to use 99291-+99292 to report critical care services.

If you are uncertain about critical care guidelines, consider this example: The pulmonologist treats a 67-yearold established patient with chronic obstructive bronchitis (491.21) at the hospital. The patient is in severe respiratory distress (786.09) with an acute exacerbation of his underlying lung disease. Despite multiple administrations of bronchodilators, treatment with steroids, and supplemental oxygen, the patient develops worsening acute respiratory failure and required intubation.

The pulmonologist documented that 45 minutes of time outside of separately billable procedures was spent caring for this critically ill patient. On the claim you would report the following:

• 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the critical care

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) linked to 99291 to show that the critical care and intubation were separate services

• 31500 (Intubation, endotracheal, emergency procedure) for the emergency intubation

• 518.81 (Acute respiratory failure) primarily and 491.21 (Obstructive chronic bronchitis; with [acute] exacerbation) linked to both 99291 and 31500 to prove medical necessity for the encounter.

Since payers frequently target 99291 for documentation errors, the payer may simply be requesting documentation to ensure accuracy of coding and documentation; this request may occur pre- or post-payment.